Provider Demographics
NPI:1427009935
Name:VIGIL, VENESSA D (OT)
Entity Type:Individual
Prefix:
First Name:VENESSA
Middle Name:D
Last Name:VIGIL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NEWPORT CENTER DR
Mailing Address - Street 2:#213
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7501
Mailing Address - Country:US
Mailing Address - Phone:949-644-1322
Mailing Address - Fax:949-644-0316
Practice Address - Street 1:2888 LONG BEACH BLVD
Practice Address - Street 2:#405
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1530
Practice Address - Country:US
Practice Address - Phone:562-595-4489
Practice Address - Fax:562-595-4063
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 6928225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOT6928BMedicare PIN